Intraoperative identification and management of renovascular anatomical variations during paraaortic lymphadenectomy: An illustrated surgical experience

Purpose Renovascular anatomical variations pose potential surgical challenges during paraaortic lymphadenectomy (PaLA) in gynecologic oncology. This study aimed to document the prevalence and intraoperative characteristics of renovascular variations encountered during PaLA, and to describe their management through detailed photographic documentation. Methods This retrospective single-center observational study included 42 patients with gynecologic malignancies (24 endometrial, 16 ovarian, 2 cervical cancers) who underwent PaLA at Ankara, Türkiye, between February 2024 and February 2025. Procedures were performed laparoscopically (n = 20, 47.6%) or via laparotomy (n = 22, 52.4%). Patients underwent preoperative contrast-enhanced abdominal CT (slice thickness ≤ 3 mm). Renovascular variations were identified intraoperatively, photographed, and classified anatomically. Results Renovascular variations were identified in 9 patients (21.4%). Inferior polar renal arteries occurred in 5 patients (11.9%): 2 bilateral, 3 unilateral right-sided. Retroaortic left renal vein was encountered in 4 patients (9.5%). Preoperative imaging identified variations in 8 of 9 cases (88.9%), with one small-caliber artery missed on imaging. No vascular injuries occurred in cases with recognized variations. All laparoscopic cases with variations (n = 4) were completed without conversion. Conclusion Renovascular variations occurred in one-fifth of patients undergoing PaLA in this series. While preoperative imaging identified most variations, intraoperative vigilance remains essential. With careful surgical technique and anatomical awareness, these variations can be safely managed, though the small sample size limits generalizability. This series provides educational documentation for gynecologic oncologists.